Midwifery intuition

Midwifery intuition is something every midwife eventually gains. It’s when you have a feeling deep down that something isn’t right, for example, a feeling that you’re headed for a caesarian section, or the feeling that you have to do a certain procedure; whether that be cannulation, a vaginal examination or escalating to a doctor. It was something I thought would come with time, not something I would be forced to learn very quickly.

I was caring for a lady with her first baby, a spontaneous labour admitted to the delivery suite at 5cm. Four hours later I was due to examine her, but I could tell from her behaviour that she was transitioning. She was 9cm, but she was involuntarily pushing with her contractions, so I knew she’d most likely be fully dilated sometime within the next 30 minutes. Just as I was trying to do my documentation, I saw a gush out of the corner of my eye. It’s rare that a lady’s waters break with a gush. It’s a common misconception that the movies have portrayed. It’s often a small trickle, and subsequently the midwife has to squint her eyes to work out whether it’s liquor or just urine (a surprisingly common occurrence).

A lady’s waters breaking usually doesn’t catch my attention too much, but it was the colour of the liquor which I was more intrigued by – thick meconium. “Great”, I thought to myself. This is a classic sign the baby is in distress, and therefore will need observations for twelve hours following delivery. The CTG (baby heart rate monitoring) was completely normal, or rather, it was as soon as I realised I had completely lost fetal contact after the waters broke. I stopped my writing halfway through and dashed over to try to find the fetal heart rate.

“Your baby’s just wiggled away from me”. I tried to sound cheery so as no to panic the mother and her partner, but after multiple position changes and adjusting the transducer to all kinds of angles, it became evident my little loss of contact had now totalled two minutes. I buzzed for another midwife, as you usually would, for some assistance in finding the fetal heart rate. A support worker opened the door and after explaining the situation, I asked for a second midwife to attend. My heart sank when I heard the news that there was no free midwife available to help me.

Nevertheless, the support worker wandered over to offer to scribe for me. I tried to tell her what I wanted to write, but my head was filled with so many different thoughts that I couldn’t put into words what I wanted to say. Whereas I would usually look to a more experienced midwife to support my decision making, I realised that I was on my own and needed to have the confidence to make the right decisions.

I explained to the women and her partner that I couldn’t monitor their baby effectively, and therefore I would recommend a ‘clip’ to put on their baby’s head to monitor the heart rate directly. I was also obliged to say there was a tiny risk of infection near the ‘clip’ site. Fear sprang into the couple’s eyes. I tried to explain that the risk is extremely low and that I had never seen a baby gain an infection from the procedure, but the word “infection” seemed to be the only thing they could focus on.

Each second continued to tick by with no fetal heart rate, so I decided it was time to put on my stern midwifery voice; “I cannot ensure your baby’s well being if I do not apply this clip”. Some may say it’s a bit manipulative, but when you’re panicked and in the moment, and the outcome of this baby is on your PIN (personal identification number), you’ll do anything to protect it and ensure your baby is born well.

This managed to convince them enough and within a few seconds the clip was on and working. She was now fully dilated as I had predicted, and I encouraged her to push with her contractions. There was good advancement, but with this being her first baby there was no knowing how long it would take for the baby to be born.

The fetal heart rate was 75bpm according to my monitor, nearly half what it was earlier. I asked the support worker to try to find a midwife, although I was practically begging by this point. To my relief, another midwife came to assist me. She didn’t stay long before she realised what was happening and dashed to get a doctor. Meanwhile, I was taking the role of chief cheerleader, urging the woman to push with her contractions. The doctor appeared and started setting up for forceps while I continued to encourage the woman to push.

The baby started crowning, and it was at this point I must have forgotten who I was, because in the chaos I found myself pushing the doctor to the side as I dashed to support the woman’s perineum. One push later and the head was delivered smoothly, followed by the baby, which thankfully, cried beautifully at delivery. The neonatal doctor attended shortly afterwards but left quickly once they could see the baby had been delivered.

Half an hour later it was time to handover so I could go home. Suturing had only just finished, and the night shift midwife walked in. “It looks awful in here”, she whispered to me. I looked around at the blood on the floor, sheets thrown everywhere and liquor all over my scrubs. I smiled awkwardly and apologised, saying that I hadn’t had the time to clean up. I handed over and stayed past my shift to help her tidy up. I went home feeling exhausted, but also thankful that everything worked out ok.

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